Incarcerated Diaphragmatic Hernia: Report of an Unusual Case* JOHN DEFRANCE, M.D.,-~ AI.BERT H. BRIDGMAN, M.D., t IVAN VUJIC, ~vl.D.,++ GULSHAN K. SEwm, M . D . t From the Veterans Administration Hospital, Asheville, North Carolina 28805
distention. His past history was significant only in that 19 years prior to this admission he had sustained a gunshot wound of the left side of his neck and chest, leaving him with a right hemiparesis. Examination in the other hospital showed blood pressur(. 130/80 mm Hg, pulse rate 100]min, temperature 99.2 F. Examination disclosed generalized tenderness and distention of the abdomen. The abdomen was tympanitic on percussion. The bowel sounds were hyperactive and high pitched. The thoracic roentgenogram was thought to be normal except for some fragments of the bullet in the left lower hemithorax and minor irregularity of the left diaphragm (Fig. 1). A barium-enema study showed complete obstruction of the colon at the level of the splenic flexure (Fig. 2). A diagnosis of carcinoma of the splenic flexure with intestinal obstruction was made, and an exploratory laparotomy was thought to he confirmatory. A decompressing transverse loop colostomy was performed. The patient was referred to the Asheville Veterans Administration Hospital for resection of his presumed cancer of the colon. The patient was well-built. The abdomen was soft and nontender.
TRAUMATIC DIAPHRAGMATIC HERNIAS are a l o n g r e c o g n i z e d , yet f r e q u e n t l y overl o o k e d , cause of i n t e s t i n a l o b s t r u c t i o n . S o n n e r t u s , in 1541, d e s c r i b e d a p ~ t i e n t w h o d i e d f r o m a s t r a n g u l a t e d s t o m a c h seven morrths a f t e r a stab w o u n d to the chest, a n d i n 1579, A m b r o i s e Pard r e p o r t e d a case of s t r a n g u l a t e d c o l o n h e r n i a t e d t h r o u g h a b u l l e t w o u n d i n the d i a p h r a g m > , to Bard e n h e w e r , 1 in 1879, p e r f o r m e d a c o l o s t o m y f o r a c u t e o b s t r u c t i o n of the c o l o n , w h i c h at a u t o p s y was f o u n d to be cat, sed by inc a r c e r a t i o n of t h e b o w e l t h r o u g h a r u p tured diaphragm. The first successful d i r e c t r e p a i r of a t r a u m a t i c d i a p h r a g m a t i c h e r n i a was p e r f o r m e d by R i o l f i in 1886.8 I t is s u r p r i s i n g t h a t e v e n w i t h such a l o n g a n d d i s t i n g u i s h e d h i s t o r y , in a recen, t series n e a r l y 40 p e r c e n t of t r a t m t a t i c h e r n i a s of the diaphragm were not recognized tmtil i n t e s t i n a l o b s t r u c t i o n or s t r a n g u l a t i o n h a d occurred. 6 We recently treated a patient w h o s e c l i n i c a l c o u r s e a g a i n r e m i n d e d us t h a t a h i g h i n d e x of s u s p i c i o n is necessary if i n t e s t i n a l o b s t r u c t i o n s e c o n d a r y to inc a r c e r a t i o n of a viscus i n a t r a u m a t i c diap h r a g m a t i c h e r n i a is to be d i a g n o s e d a n d treated accurately and t)romptly.
R e p o r t of a Case A 52-year-old white man entered another hospital with a 48-hour history of crampy upper abdominal pain, nausea, vomiting, constipation, and abdominal * Received for publication April 18, 1975. t Division of Cardiovascular and Thoracic Surgery. + Department of Diagnostic Radiology. Address reprint requests to Dr. Sethi.
Fro. 1. Chest x-rays on admission, showing fragments of bullet in the lower part of the left bemithorax (arrows). Note irreg-ularity of the left diaphragm. 158
Dis. Col.&Reet. March 1976
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]59
FIG. 3. Chest x-ray (following colostomy procedure). Air is present under both diaphragms. There is no roentgeno~aphic evidence of diaphragmatic hernia.
FIe. 2. Barium-enema study, showing complete obstruction of the colon at the level of the splenic flexure, thought to be due to cancer.
The bowel sounds were normal. Chest x~ray again showed fragments of the bullet in the lower part of the left hemithorax. Air was present under both diaphragms, and this seemed to preclude evidence of diaphragmatic hernia (Fig. 3). However, the past history of penetrating trauma to the left thorax, which had produced some irregularity of the left hemidiaphragm, and the complete absence of symptoms suggestive of cancer of the colon at this time, prompted us to repeat the barium-enema examination of the colon, both through the anus and through the distal limb of the transverse co]ostomy. Barium from the colostomy partially filled a kinked loop of colon, which was found to be above the left diaphragm. This loop of colon was completely obstructed distally (Fig. 4). The patient was explored through a left anterolateral thoracotomy incision with a presumptive diagnosis of traumatic diaphragmatic hernia with incarceration of the colon. We believed that technically it would be easier to divide the adhesions between the incarcerated colon and lung, and to repair the diaphragmatic defect, through the transthoracic approach. At operation, a defect in the diaphragm 2 cm in diameter was found. There were multiple dense adhesions between the pulmo-
Flc. 4. Barium-enema examination through distal limb of transverse colostomy. The kinked loop of opacified colon is present above the diaphragm, and it is completely obstructed distally.
160
DE FRANCE,
nary parenchyma and the herniated colon and omentum. A part of the herniated omentum appeared to be necrotic. The defect in the diaphragm was enlarged to allow the colon to be reduced into the peritoneal cavity. The necrotic portion of the omentum was resected. The hernia was repaired with nonabsorbable sutures. The postoperative course was uncomplicated. The colostomy was closed three weeks later with return of normal bowel function.
Discussion Intra-abdominal organs can herniate through defects in the d i a p h r a g m that are created by blunt or penetrating trauma to the chest or abdomen. T h o u g h we usually can cite accidems, gunshots, or stab wounds as the cause, unfortunately some diaphragmatic hernias occur following operations on the diaphragm. Hernias through incisions in the diaphragm used for hiatal h e r n i o r r h a p h y or for thoracoabdominal approaches have been reported,* and a defect in the diaphragm can also occur due to erosion by a large-bore tube used to drain the chest or abdomen. 9 Occasionally, when a patient with trauma undergoes abdominal or thoracic exploration, a laceration of the diaphragm may be overlooked; even if it is repaired, postoperative herniation through the defect may occur in a significant n u m b e r of patients. 7 Most hernias o c c u r through the left leaf of the diap h r a g m since the liver provides protection on the right side. T h e clinical presentation of posttraumatic diaphragmatic hernia can occur in three phases. 2 T h e diaphragmatic hernias which present acutely following injury are often hernias through large defects in the diaphragm. In these cases cardiorespiratory distress and shock are frequently the presenting symptoms because of compression of the heart or lungs. These symptoms may also be due to associated injuries of other organs. T h e physical signs of tracheal shift, scaphoid abdomen, dullness or tympany of the lower thorax, and bowel
ET AL.
Dis. CoL & Reef. March 1976
sounds heard in the chest will suggest the diagnosis. RoentgenogTams of the chest may show mediastinal displacement, diaphragmatic elevation caused by gas bubble of the herniated stomach, or multiple airfluid levels in the chest. During an interval period, the diaphragmatic hernia may mimic the symptoms of peptic ulcer, pancreatitis, gallbladder disease, coronary-artery disease, or in.termittent or partial intestinal obstruction. W h e n a small defect is created in the diaphragm, it may be initially occluded by the omentum. However, respiratory movements of the d i a p h r a g m and the ~ a d i e n t between the negative intrapleural pressure and positive intraperitoneal pressure encourage further herniation of various intraabdominal organs. Often a heavy meal or straining effort may precipitate incarceration of intestine. This may produce intestinal obstruction or strangulation. If stomach is the herniated viscus, pain with early vomi,ting and absence of abdominal distention is usually the initial clinical picture. When the small intestine or colon becomes incarcerated in a diaphragmatic hernia, the pain is usually followed by vomiting and distention of the abdomen. Should strangulation occur in either case, gastroin, testinal bleeding, intestinal perforation, peritonitis, and sepsis may ensue. Making the correct diagnosis is facilitated by the chest x-ray, where besides the signs mentioned previously, there may be pleural effusion, atelectasis, and irregularity or obscuring of the diaphragmatic margins. Ancillary diagnostic procedures including p n e u m o p e r i t o n e u m and thoracen, tesis have been recommended. T h e former is rarely necessary, and the latter carries with it the hazard of producing empyema and fistula formation, u U p p e r a n d / o r lower gastrointestinal barium examination, even in the acutely ill patient, may be necessary for clear definition of the abnormality, a
Volume 19 Number 2
INCARCERATED DIAPHRAGMATIC HERNIA
O p e r a t i v e therapy is necessary at any phase, a n d may be lifesaving in b o t h the acute a n d the s t r a n g u l a t i n g obstructive phases. A.lthough there is some con.troversy r e g a r d i n g the surgical approach, the most reasonable one seenls to be to explore t h r o u g h the a b d o m e n w h e n the h e r n i a occurs acu, tely following t r a u m a because of possible associated i n i u r i e s to various i n t r a - a b d o m i n a l organs. A transthoracic approach is a p p r o p r i a t e w h e n the p a t i e n t is first seen long after his i n j u r y , because usually there are dense adhesions b e t w e e n the l u n g a n d the h e r n i a t e d organs, as we e n c o u n t e r e d in our p:ttient, c' O1 course, the circumstances of each p a t i e n t must be considered i n d i v i d u a l l y a n d the approaches, w h e t h e r t r a n s a b d o n d n a l or transthoracic, will wuy. T h e d i a p h r a g m should be repaired with i n t e r r u p t e d nona b s o r b a b l e sutures a n d i n t e s t i n a l decompression should be m a i n t a i n e d u n t i l spont a n e o u s bowel activity returns. Sulnmal'y T r a u m a t i c d i a p h r a g m a t i c hernias, alt h o u g h q u i t e c o m m o n , are f i e q u e n t l y overlooked as a cause of i n t e s t i n a l obstruction. T h e h e r n i a may produce significant syntptoms acutely or manifest itself m a n y years following the i n i t i a l injury. A high i n d e x of suspicion is necessary to diagnose intestinal o b s t r u c t i o n d u e to incarcera.ted diaphragmatic hernia. The operation should be performed through tlm transab-
161
d o m i n a l a p p r o a c h w h e n h e r n i a occurs acutely, a n d the transtho.racic a p p r o a c h is r e c o m m e n d e d w h e n h e r n i o r r h a p h y is performed long after the time of i n j u r y . A case of incarcerated t r a u m a t i c diaphragmatic h e r n i a that occurred 19 years following a g u n s h o t w o u n d of the chest is reported. T h e i n t e s t i n a l o b s t r u c t i o n was initially t h o u g h t to be d u e to cancer of the splenic flexure oE the colon.
References l. Bardenhewer E.: Ein Fall yon Hernia diaphragmatica. Klin Wochenschur 16: 195, 1879 2. Carter BN, Giusefli J, FelsonB: Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther Nud Med 65: 56, 1951 3. Cartel R, Brewer LA III: Strangulating diaphragmatic hernia. Ann Thorac Surg 12: 281, 1971 4. Coppinger WR: Rupture of diaphragm following repair of hiatal hernia: Report of two cases. Arch Surg 80: 998, 1960 5. Hamby WB (ed): The Case Reports and Autopsy Records of Ambroise Par6. Springfield, Ill., Charles C Thomas, 1960, p 50 6. Mansour KA, Clements JL, Hatcher CR, et al: Diaphragmatic hernia caused by trauma: Experience with 35 cases. Am Surg 41: 97, 1975 7. Naderio EA: Discussion. Ann Thorac Surg 12: 289, 1971 8. Riolfi: Quoted by Hedblom CA: Diaphragmatic hernia: A study of three hundred and seventy-eight cases in which operation was performed. JAMA 85: 947, 1925 9. Schneider CF: Traumatic diaphragmatic hernia. Am J Surg 91: 290, 1956 10. Schneider CF: Traumatic hernia of the diaphragm. In Nyhus LM, Harkins HN (eds): Hernia. Philadelphia, J. B. Lippincott Company, 1964, chapt 36, p 568 11. Sullivan RE: Strangulation and obstruction in diaphra~natic hernia due to direct trauma: Report of two cases and review of the English literature. J Thorac Cardiovasc Surg 52: 725, 1966
distention. His past history was significant only in that 19 years prior to this admission he had sustained a gunshot wound of the left side of his neck and chest, leaving him with a right hemiparesis. Examination in the other hospital showed blood pressur(. 130/80 mm Hg, pulse rate 100]min, temperature 99.2 F. Examination disclosed generalized tenderness and distention of the abdomen. The abdomen was tympanitic on percussion. The bowel sounds were hyperactive and high pitched. The thoracic roentgenogram was thought to be normal except for some fragments of the bullet in the left lower hemithorax and minor irregularity of the left diaphragm (Fig. 1). A barium-enema study showed complete obstruction of the colon at the level of the splenic flexure (Fig. 2). A diagnosis of carcinoma of the splenic flexure with intestinal obstruction was made, and an exploratory laparotomy was thought to he confirmatory. A decompressing transverse loop colostomy was performed. The patient was referred to the Asheville Veterans Administration Hospital for resection of his presumed cancer of the colon. The patient was well-built. The abdomen was soft and nontender.
TRAUMATIC DIAPHRAGMATIC HERNIAS are a l o n g r e c o g n i z e d , yet f r e q u e n t l y overl o o k e d , cause of i n t e s t i n a l o b s t r u c t i o n . S o n n e r t u s , in 1541, d e s c r i b e d a p ~ t i e n t w h o d i e d f r o m a s t r a n g u l a t e d s t o m a c h seven morrths a f t e r a stab w o u n d to the chest, a n d i n 1579, A m b r o i s e Pard r e p o r t e d a case of s t r a n g u l a t e d c o l o n h e r n i a t e d t h r o u g h a b u l l e t w o u n d i n the d i a p h r a g m > , to Bard e n h e w e r , 1 in 1879, p e r f o r m e d a c o l o s t o m y f o r a c u t e o b s t r u c t i o n of the c o l o n , w h i c h at a u t o p s y was f o u n d to be cat, sed by inc a r c e r a t i o n of t h e b o w e l t h r o u g h a r u p tured diaphragm. The first successful d i r e c t r e p a i r of a t r a u m a t i c d i a p h r a g m a t i c h e r n i a was p e r f o r m e d by R i o l f i in 1886.8 I t is s u r p r i s i n g t h a t e v e n w i t h such a l o n g a n d d i s t i n g u i s h e d h i s t o r y , in a recen, t series n e a r l y 40 p e r c e n t of t r a t m t a t i c h e r n i a s of the diaphragm were not recognized tmtil i n t e s t i n a l o b s t r u c t i o n or s t r a n g u l a t i o n h a d occurred. 6 We recently treated a patient w h o s e c l i n i c a l c o u r s e a g a i n r e m i n d e d us t h a t a h i g h i n d e x of s u s p i c i o n is necessary if i n t e s t i n a l o b s t r u c t i o n s e c o n d a r y to inc a r c e r a t i o n of a viscus i n a t r a u m a t i c diap h r a g m a t i c h e r n i a is to be d i a g n o s e d a n d treated accurately and t)romptly.
R e p o r t of a Case A 52-year-old white man entered another hospital with a 48-hour history of crampy upper abdominal pain, nausea, vomiting, constipation, and abdominal * Received for publication April 18, 1975. t Division of Cardiovascular and Thoracic Surgery. + Department of Diagnostic Radiology. Address reprint requests to Dr. Sethi.
Fro. 1. Chest x-rays on admission, showing fragments of bullet in the lower part of the left bemithorax (arrows). Note irreg-ularity of the left diaphragm. 158
Dis. Col.&Reet. March 1976
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Volume 19 Number 2
INCARCERATED DIAPHRAGMATIC HERNIA
]59
FIG. 3. Chest x-ray (following colostomy procedure). Air is present under both diaphragms. There is no roentgeno~aphic evidence of diaphragmatic hernia.
FIe. 2. Barium-enema study, showing complete obstruction of the colon at the level of the splenic flexure, thought to be due to cancer.
The bowel sounds were normal. Chest x~ray again showed fragments of the bullet in the lower part of the left hemithorax. Air was present under both diaphragms, and this seemed to preclude evidence of diaphragmatic hernia (Fig. 3). However, the past history of penetrating trauma to the left thorax, which had produced some irregularity of the left hemidiaphragm, and the complete absence of symptoms suggestive of cancer of the colon at this time, prompted us to repeat the barium-enema examination of the colon, both through the anus and through the distal limb of the transverse co]ostomy. Barium from the colostomy partially filled a kinked loop of colon, which was found to be above the left diaphragm. This loop of colon was completely obstructed distally (Fig. 4). The patient was explored through a left anterolateral thoracotomy incision with a presumptive diagnosis of traumatic diaphragmatic hernia with incarceration of the colon. We believed that technically it would be easier to divide the adhesions between the incarcerated colon and lung, and to repair the diaphragmatic defect, through the transthoracic approach. At operation, a defect in the diaphragm 2 cm in diameter was found. There were multiple dense adhesions between the pulmo-
Flc. 4. Barium-enema examination through distal limb of transverse colostomy. The kinked loop of opacified colon is present above the diaphragm, and it is completely obstructed distally.
160
DE FRANCE,
nary parenchyma and the herniated colon and omentum. A part of the herniated omentum appeared to be necrotic. The defect in the diaphragm was enlarged to allow the colon to be reduced into the peritoneal cavity. The necrotic portion of the omentum was resected. The hernia was repaired with nonabsorbable sutures. The postoperative course was uncomplicated. The colostomy was closed three weeks later with return of normal bowel function.
Discussion Intra-abdominal organs can herniate through defects in the d i a p h r a g m that are created by blunt or penetrating trauma to the chest or abdomen. T h o u g h we usually can cite accidems, gunshots, or stab wounds as the cause, unfortunately some diaphragmatic hernias occur following operations on the diaphragm. Hernias through incisions in the diaphragm used for hiatal h e r n i o r r h a p h y or for thoracoabdominal approaches have been reported,* and a defect in the diaphragm can also occur due to erosion by a large-bore tube used to drain the chest or abdomen. 9 Occasionally, when a patient with trauma undergoes abdominal or thoracic exploration, a laceration of the diaphragm may be overlooked; even if it is repaired, postoperative herniation through the defect may occur in a significant n u m b e r of patients. 7 Most hernias o c c u r through the left leaf of the diap h r a g m since the liver provides protection on the right side. T h e clinical presentation of posttraumatic diaphragmatic hernia can occur in three phases. 2 T h e diaphragmatic hernias which present acutely following injury are often hernias through large defects in the diaphragm. In these cases cardiorespiratory distress and shock are frequently the presenting symptoms because of compression of the heart or lungs. These symptoms may also be due to associated injuries of other organs. T h e physical signs of tracheal shift, scaphoid abdomen, dullness or tympany of the lower thorax, and bowel
ET AL.
Dis. CoL & Reef. March 1976
sounds heard in the chest will suggest the diagnosis. RoentgenogTams of the chest may show mediastinal displacement, diaphragmatic elevation caused by gas bubble of the herniated stomach, or multiple airfluid levels in the chest. During an interval period, the diaphragmatic hernia may mimic the symptoms of peptic ulcer, pancreatitis, gallbladder disease, coronary-artery disease, or in.termittent or partial intestinal obstruction. W h e n a small defect is created in the diaphragm, it may be initially occluded by the omentum. However, respiratory movements of the d i a p h r a g m and the ~ a d i e n t between the negative intrapleural pressure and positive intraperitoneal pressure encourage further herniation of various intraabdominal organs. Often a heavy meal or straining effort may precipitate incarceration of intestine. This may produce intestinal obstruction or strangulation. If stomach is the herniated viscus, pain with early vomi,ting and absence of abdominal distention is usually the initial clinical picture. When the small intestine or colon becomes incarcerated in a diaphragmatic hernia, the pain is usually followed by vomiting and distention of the abdomen. Should strangulation occur in either case, gastroin, testinal bleeding, intestinal perforation, peritonitis, and sepsis may ensue. Making the correct diagnosis is facilitated by the chest x-ray, where besides the signs mentioned previously, there may be pleural effusion, atelectasis, and irregularity or obscuring of the diaphragmatic margins. Ancillary diagnostic procedures including p n e u m o p e r i t o n e u m and thoracen, tesis have been recommended. T h e former is rarely necessary, and the latter carries with it the hazard of producing empyema and fistula formation, u U p p e r a n d / o r lower gastrointestinal barium examination, even in the acutely ill patient, may be necessary for clear definition of the abnormality, a
Volume 19 Number 2
INCARCERATED DIAPHRAGMATIC HERNIA
O p e r a t i v e therapy is necessary at any phase, a n d may be lifesaving in b o t h the acute a n d the s t r a n g u l a t i n g obstructive phases. A.lthough there is some con.troversy r e g a r d i n g the surgical approach, the most reasonable one seenls to be to explore t h r o u g h the a b d o m e n w h e n the h e r n i a occurs acu, tely following t r a u m a because of possible associated i n i u r i e s to various i n t r a - a b d o m i n a l organs. A transthoracic approach is a p p r o p r i a t e w h e n the p a t i e n t is first seen long after his i n j u r y , because usually there are dense adhesions b e t w e e n the l u n g a n d the h e r n i a t e d organs, as we e n c o u n t e r e d in our p:ttient, c' O1 course, the circumstances of each p a t i e n t must be considered i n d i v i d u a l l y a n d the approaches, w h e t h e r t r a n s a b d o n d n a l or transthoracic, will wuy. T h e d i a p h r a g m should be repaired with i n t e r r u p t e d nona b s o r b a b l e sutures a n d i n t e s t i n a l decompression should be m a i n t a i n e d u n t i l spont a n e o u s bowel activity returns. Sulnmal'y T r a u m a t i c d i a p h r a g m a t i c hernias, alt h o u g h q u i t e c o m m o n , are f i e q u e n t l y overlooked as a cause of i n t e s t i n a l obstruction. T h e h e r n i a may produce significant syntptoms acutely or manifest itself m a n y years following the i n i t i a l injury. A high i n d e x of suspicion is necessary to diagnose intestinal o b s t r u c t i o n d u e to incarcera.ted diaphragmatic hernia. The operation should be performed through tlm transab-
161
d o m i n a l a p p r o a c h w h e n h e r n i a occurs acutely, a n d the transtho.racic a p p r o a c h is r e c o m m e n d e d w h e n h e r n i o r r h a p h y is performed long after the time of i n j u r y . A case of incarcerated t r a u m a t i c diaphragmatic h e r n i a that occurred 19 years following a g u n s h o t w o u n d of the chest is reported. T h e i n t e s t i n a l o b s t r u c t i o n was initially t h o u g h t to be d u e to cancer of the splenic flexure oE the colon.
References l. Bardenhewer E.: Ein Fall yon Hernia diaphragmatica. Klin Wochenschur 16: 195, 1879 2. Carter BN, Giusefli J, FelsonB: Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther Nud Med 65: 56, 1951 3. Cartel R, Brewer LA III: Strangulating diaphragmatic hernia. Ann Thorac Surg 12: 281, 1971 4. Coppinger WR: Rupture of diaphragm following repair of hiatal hernia: Report of two cases. Arch Surg 80: 998, 1960 5. Hamby WB (ed): The Case Reports and Autopsy Records of Ambroise Par6. Springfield, Ill., Charles C Thomas, 1960, p 50 6. Mansour KA, Clements JL, Hatcher CR, et al: Diaphragmatic hernia caused by trauma: Experience with 35 cases. Am Surg 41: 97, 1975 7. Naderio EA: Discussion. Ann Thorac Surg 12: 289, 1971 8. Riolfi: Quoted by Hedblom CA: Diaphragmatic hernia: A study of three hundred and seventy-eight cases in which operation was performed. JAMA 85: 947, 1925 9. Schneider CF: Traumatic diaphragmatic hernia. Am J Surg 91: 290, 1956 10. Schneider CF: Traumatic hernia of the diaphragm. In Nyhus LM, Harkins HN (eds): Hernia. Philadelphia, J. B. Lippincott Company, 1964, chapt 36, p 568 11. Sullivan RE: Strangulation and obstruction in diaphra~natic hernia due to direct trauma: Report of two cases and review of the English literature. J Thorac Cardiovasc Surg 52: 725, 1966
![[Anterolateral diaphragmatic hernia: case report].](/assets/img/hold.png)
